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L. Kevin Hamberger, Ph.D. Department of Family and Community Medicine
Medical College of Wisconsin
Injuries Mental and physical health and well-being Health Care Utilization
As a Mental Health problem Depression, Anxiety Alcohol/drug abuse
As a Relationship problem Sexual dysfunction Partner as identified patient
As a Child-Related problem Suspected child abuse Child behavior problem
As multiple, stress-related physical complaints
As a “compliance” problem Medication Obstetrics Follow-up for specialty care
Compared to no IPV, healthcare utilization by victims was higher across all categories
As time from the last assault increased, utilization rates decreased
5 years after the final assault, victims’ utilization 20% higher than non-victims
Rivera, et al. (2007)
Children of battered women experience more healthcare utilization and costs than children of non-battered women Mental health services Primary care visits Specialty care Pharmacy services Emergency services (for children directly exposed)
Rivera et al. (2008)
KC 50 y/o African American woman, self-employed
Presentation to FP: “I’m having problems sleeping, feeling stressed all the time, and depressed.”
Sleep onset and interruption insomnia Headaches Nightmares Crying spells Worry Difficulty concentrating and inability to do her job Decreased appetite
She did not mention the assault to her PMD Family gathering
Punched and strangled by husband
Feared for her life
Intrusive thoughts Avoidance of certain situations
B.H. 55 y/o African American woman Married 30 years; 4 adult children Homemaker and part time work with her church
Frequent clinic visitor High blood pressure and headaches Depression
Sadness Guilt feelings Sleep interruption insomnia Overeating and weight gain Low energy and decreased motivation Feelings of hopelessness
Not suicidal Low self-esteem Frequent crying spells
PMD uncovered abuse via case finding
C.O. 28 y/o White female Currently unemployed History of bi-polar disorder and alcohol abuse
Complaints of low back pain
No pathophysiology identified following comprehensive testing and diagnostic studies abuse was discovered via case finding
P.T. 58 Y/O White female Married 33 years Recent empty nest Recent part time employment after years of
homemaking Presented to PMD with anxiety that was not
responsive to medications
Uncontrollable worry and apprehension that “something bad” was going to happen
Increased muscle tension Fatigue Restlessness Increased absenteeism from work
IPV unveiled through case finding
Ongoing debate Studies have not uniformly shown screening to result in
decreased violence or improved health MacMillan et al. (2009), Klevens et al. (2012)
IPV screening and counseling one of 8 prevention services to be offered to women with no cost sharing
US Preventive Services Task Force gives IPV screening in primary care settings a B recommendation – IPV screening has moderate net benefit Service is recommended and should be offered Adequate screening instruments Adequate evidence of effective interventions Risk of harms from screening no greater than small
HITS – Hurt, Insult, Threaten, Scream (Sherin et al., 1998)
OVAT-- Ongoing Violence Assessment Tool (Ernst et al., 2004)
STaT -- Slapped, Threatened, Throw (Paranjape et al., 2006)
HARK– Humiliation, Afraid, Rape, Kick (Sohal et al., 2007)
WAST -- Woman Abuse Screening Tool (Brown et al., 2000)
PVS – Partner Violence Screen (Feldhaus et al., 1997)
Resulted in large-scale screening
Been sustainable
External attempts to induce change have not been effective Professional association position statements Accreditation efforts Required cme for licensure
Reliance on community resources to support change
has been successful…… But there not enough resources And when the funding goes…….
Knowledge
Self efficacy
Clinical skill Hamberger et al. (2004)
Systematic reviews Waalen et al., (2000) O’Campo et al., (2011)
Empirical studies
Minsky-Kelly et al. (2005) Hamberger et al. (2010) Sims et al. (2011)
•Privacy concerns •Time constraints
•Patient f low •Professional/Personal discomfort with subject
System-level interventions at the departmental level
Increase privacy Modify patient flow Provide department-level CQI feedback Stress/vicarious trauma management Ongoing in-service skills training review
L. Kevin Hamberger, Ph.D. Bruce Ambuel, Ph.D. Mary Beth Phelan, M.D. Marlene Melzer-Lange, M.D. Marie Wolff, Ph.D. Amy Kistner, M.S. Clare Guse, M.S.
1) Health Care Advocates—Selected staff receive intensive training in IPV & health
2) Collaboration w/ advocacy agencies & experts 3) Saturation training of all staff 4) Policies & procedures 5) Continuous Quality Improvement 6) Primary prevention
Integration of facts into the healthcare picture Why is this a healthcare problem? Why is this information relevant to HCPs? Why should HCPs make IPV part of their practice?
What skills are involved to effectively work with IPV survivors?
Assure confidentiality Provide emotional support Provide community resource information Danger assessment Safety planning Offer follow-up Documentation
A couple came in to the clinic – each with their own appointment
A couple came in to the clinic – each with their own appointment
The male checks in for both self and partner
A couple came in to the clinic – each with their own appointment
The male checks in for both self and partner Another receptionist observes suspicious behavior
He was talking for his partner Woman partner looked subservient He was rude and aggressive with reception staff
A couple came in to the clinic – each with their own appointment
The male checks in for both self and partner Another receptionist observes suspicious behavior
He was talking for his partner Woman partner looked subservient He was rude and aggressive with reception staff
Receptionist observed bruises on the female patient
Receptionist surreptitiously called the MOA Described the male patient’s behavior Described bruises noted Expressed concern about abuse
Receptionist surreptitiously called the MOA Described the male patient’s behavior Described bruises noted Expressed concern about abuse
MOA decides to call the female patient separately from the male to room separately (invoked clinic policy)
Female patient was roomed MOA notified MD of the situation and separate
rooming strategy and MD agreed MD begins to see female patient with aid of interpreter MOA rooms male patient in a NON-Adjacent room
28 y/o AAF attends clinic for CPE Reports upon screening that she is in a violent
relationship
Partner has threatened to kill her Partner followed her into local police station
where she attempted to make a report She was referred to family court for TRO Partner accompanied her to family court offices
and threatened to kill her if she followed through with TRO
She desisted and returned home Partner took her rent money
Physician asked if she wanted to speak to the Health Advocate
Health Advocate invited to exam room Conducted violence assessment Conducted safety planning Provided resource information Scheduled follow-up contacts
Patient asked for help accessing shelter Advocate contacted shelter
No room No alternatives provided Advocate located area shelter alternatives
Shelter director later contacted for problem solving
Education
Education Discipline and job-specific roles
Education Discipline and job-specific roles Clinic policies and procedures
IPV screening Patients seen alone for part of medical encounter Collaboration with community agencies
Strategies to Measure Effectiveness of Healthcare-Based Domestic
Violence Screening and Intervention
May not be under the control of either the patient/survivor or the healthcare provider Hamberger, Rhodes, & Brown (2014)
Practitioner
Health system
Patient
Clinicians reported significant increases in:
1) Self-efficacy
2) Understanding of referral resources
3) Understanding of legal requirement
4) Clinic’s capacity to facilitate IPV intervention
5) Staff well prepared
6) Increased screening
Compared to “usual care” control clinics, intervention clinics showed: Implementation of new policies and procedures for IPV
screening and intervention Increased locations and numbers of patient education
materials on IPV Increased screening documentation
Changes continued at 2-year follow-up, suggesting
sustained change
SIGNIFICANT FINDINGS favoring intervention clinics IPV screening by doctor or nurse Disclose IPV to doctor or nurse Discuss IPV with someone at a clinic or hospital
Fewer symptoms of injury Drop in clinic visits over time
Randomized controlled trial – 48 total clinics Similar components to Healthcare Can Change From
Within Practice-based training sessions Embedded domestic violence advocate Prompt to ask about abuse
Results Intervention practices recorded significantly more
IPV referrals to advocacy Disclosures of IPV from patients
Intervention is cost-effective Devine et al., 2012
IPV is a public health problem with a tremendous morbidity burden for individual survivors and for society
Efforts to address IPV as a health problem are evolving and showing promise
Systems change that involves a multi-disciplinary approach appears to be the most promising approach to increasing office-based IPV screening and brief intervention
More research using RCTs are needed to validate the impact of healthcare-based screening and brief interventions to prevent and end IPV
Methodological improvements are needed
Ambuel, B., Hamberger, LK, Guse, C, Melzer-Lange, M., Phelan, MB, & Kistner, A. (2013). Healthcare can change from within: Sustained improvement in the healthcare response to intimate partner violence. Journal of Family Violence, 28, 833-847.
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Devine, A, Spencer, A, Eldredge, S., Norman, R., & Feder, G. (2012). Cost-effectiveness of Identification and Referral to Improve Safety (IRIS), a domestic violence training and support programe for primary care: a modelling study based on a randomised control trial. BMJ Open, 2:e001008. doi:10.1136/bmjopen-2012-0011008.
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Hamberger, LK, Guse, CE, Boerger, J, Minsky, D, Pape, D, & Folsom, C. (2004). Evaluation of a health care provider training program to identify and help partner violence victims. Journal of Family Violence, 19, 1-11.
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